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CMS Finalizes MACRA Implementation, Quality Payment Program

CMS finalized the Quality Payment Program and other MACRA implementation rules that will go into effect on Jan. 1, 2017.

October 14, 2016 - CMS released the long-awaited final rule on MACRA implementation earlier today, which stated that the new value-based reimbursement system will start on Jan. 1, 2017.

The final MACRA implementation rule will replace the Sustainable Growth Rate by implementing the Quality Payment Program. Eligible clinicians will participate in either the Merit-Based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM) starting in January 2017, which will affect 2019 Medicare reimbursements.

“Today, we’re proud to put into action Congress’s bipartisan vision of a Medicare program that rewards clinicians for delivering quality care to their patients,” said Sylvia M. Burwell, HHS Secretary. “Designed with input from thousands of clinicians and patients across the country, the new Quality Payment Program will strengthen our healthcare system for patients, clinicians and the American taxpayer.”

CMS made several changes from the MACRA implementation proposed rule in response to stakeholder feedback, including flexible MACRA attestation options, additional resources for small practices, more opportunities to join an Advanced APM, and statutory domain consolidation into one program for quality improvement.

Under the final rule, 2017, and possibly 2018, will act as a transition year in which eligible clinicians can select one of four MACRA attestation options. Clinicians can choose to report to MIPS for a full 90-day period or the full year to qualify for maximum value-based incentive payments.

Clinicians can also elect to report one measure from the quality or improvement activities MIPS performance categories or report on the required measures of the advancing care information component for at least a 90-day period to avoid negative MIPS payment adjustments in 2019.

The last MACRA attestation option involves full Advanced APM participation in 2017 to qualify for a five percent value-based incentive payment in 2019.

“We anticipate that the iterative learning and development period will last longer than the first year, CY 2017, of the program as we move towards a steady state; therefore, we envision CY 2018 to also be transitional in nature to provide a ramp-up of the program and of the performance thresholds,” stated CMS in an accompanying executive summary. “We anticipate making proposals on the parameters of this second transition year through rule-making in 2017.”

For small, independent, and rural practices, CMS finalized additional resources to help eligible clinicians succeed under the new value-based reimbursement program. The federal agency has set aside $100 million for technical assistance that can used through contracts with quality improvement organizations, regional health collaboratives, and other approved groups. The assistance will be available to MIPS-eligible clinicians in practices of 15 or fewer MIPS-eligible clinicians.

However, CMS elected not to lower MIPS exclusion thresholds from $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients despite stakeholder requests. The federal agency also will not implement virtual groups, which allow clinicians to be assessed as a group under MIPS, during the transition. Groups of 10 or more clinicians also cannot form a virtual group, according to the final rule.

CMS stated that the final rule should bolster support for small, independent, and rural practices, leading to higher participation rates than the Physician Quality Reporting System. Each practice size is projected to have at least an 80 percent participation rate, down from 90 percent in the primary analysis, and at least 80 percent of clinicians in small and solo practices with nine or fewer clinicians are estimated to receive a positive or neutral MIPS payment adjustment in the transition year, CMS reported.

Additionally, the final rule added new Advanced APM participation options. CMS may include the Medicare Shared Savings Program Track 1 to the list of Advanced APMs in 2018. MSSP Tracks 2 and 3 are already approved, but the federal agency plans to test a payment model that would include more limited downside risk in Track 1.

Under the final rule, CMS also separated Advanced APMs into two categories: Advanced APMs and Other Payer Advanced APMs. To be an Other Payer Advanced APM, a reimbursement agreement with a payer (private or public) must require certified EHR use, provide payment based quality measures comparable to those in the MIPS quality performance category, and mandate participants to bear more than nominal financial risk.

CMS intends to finalize a list of Advanced APMs by no later than Jan. 1, 2017.

In terms of MIPS, the final rule stated that eligible clinicians will still have to report at least six quality performance measures or on one specialty-specific measure set in 2017, but CMS has reduced the number of improvement activities required to earn maximum credit. Eligible clinicians can report four medium-weighted or two high-weighted improvement activities in 2017 rather than the proposed six medium-weighted and three high-weighted activities.

Small and rural practices as well as practices residing in geographic health professional shortage areas and non-patient facing MIPS eligible clinicians will only have to report on one high-weighted or two medium-weighted activities.

CMS also reduced the number of advancing care information measures from eleven to five measures. Eligible clinicians who report on all five measures would earn 50 percent of the category score and additional points would be awarded for more quality reporting. During the transition year, the federal agency will award bonus points for improvement activities that use certified EHR technology and for public health or clinical data registry reporting.

For the transition year, CMS also decreased the cost performance category weight to zero percent.

“It’s time to modernize the Medicare physician payment system to be more streamlined and effective at supporting high-quality patient care,” stated Andy Slavitt, CMS Acting Administrator. “To be successful, we must put patients and clinicians at the center of the Quality Payment Program. A critical feature of the program will be implementing these changes at a pace and with options that clinicians choose. Today’s policies are designed to get all eligible clinicians to participate in the program, so they are set up for successful care delivery as the program matures.”

Healthcare stakeholders will have 60 days to submit comments on the MACRA implementation final rule.